37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 530955 |
Time | |
Date | 200111 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Flight Phase | ground : parked ground : maintenance |
Person 1 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Qualification | technician : powerplant technician : fcc technician : airframe |
Experience | maintenance avionics : 7 maintenance technician : 18 |
ASRS Report | 530955 |
Person 2 | |
Affiliation | company : air carrier |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : published procedure |
Resolutory Action | none taken : detected after the fact |
Consequence | other other |
Factors | |
Maintenance | contributing factor : non availability of parts contributing factor : schedule pressure contributing factor : work cards performance deficiency : non compliance with legal requirements performance deficiency : inspection |
Supplementary | |
Problem Areas | Chart Or Publication Company Environmental Factor Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MAINT MANUAL |
Narrative:
On 11/sun/2001 shift avionics line. I was given an assignment by my lead avionics tech. The work assignment was aircraft xyz located at the holding area. The job assignment was replacement of the first officer's horizontal situation indicator and work a log book discrepancy involving troubleshooting an automatic pilot problem. I was told the horizontal situation indicator was robbed for aircraft xya. My lead tech told me the part was ordered earlier during a different shift and was pulled from stock, and ready for, pick up at line stores. I retrieved the part from stores and proceeded to the aircraft and replaced the first officers horizontal situation indicator 'HSI', per the avionics job card. This included the use of a 'test box.' ok for service. I then trouble shot the automatic pilot discrepancy and found I needed a mode control panel. I assigned a tech to assist in the removal and replacement of the MCP. The aircraft was moved from the holding area to gate X by maintenance. After installing the mode control panel. I was notified days later that the 'HSI' component that I replaced on aircraft xyz (first officer's) was the wrong part number. The wrong part number was ordered during shift for aircraft xyz. A request from engineering and records to remove the 'HSI' and replace with another part. This was accomplished 11/wed/2001 in ZZZ1, us. Callback conversation with reporter revealed the following information: the reporter stated the EFIS indicator had been ordered on the previous shift and was installed with a job card. The reporter said the job card has the same information as the maintenance manual for installation and testing of the instrument. The reporter stated the instrument tested ok after installation and the part number was entered in the maintenance computer and was accepted. The reporter said neither the job card nor the maintenance manual had any information on effectivity of the part for different models of the B737. The reporter stated the carrier has had 24 incidents of the wrong part installed and does not appear to be making improvements. The reporter said no standard exists to have the part number painted on the part as some have numbers and others none. The reporter stated the maintenance computer has major flaws as it is supposed to be programmed to reject a part that is not on the aircraft effectivity list, but most times does not perform this function.
Original NASA ASRS Text
Title: A B737-400 WAS DISPATCHED IN NON COMPLIANCE WITH THE INCORRECT EFIS NAVIGATIONAL DISPLAY INSTALLED. CAUSED BY PUBLICATION DEFICIENCY.
Narrative: ON 11/SUN/2001 SHIFT AVIONICS LINE. I WAS GIVEN AN ASSIGNMENT BY MY LEAD AVIONICS TECH. THE WORK ASSIGNMENT WAS ACFT XYZ LOCATED AT THE HOLDING AREA. THE JOB ASSIGNMENT WAS REPLACEMENT OF THE FO'S HORIZONTAL SIT INDICATOR AND WORK A LOG BOOK DISCREPANCY INVOLVING TROUBLESHOOTING AN AUTO PLT PROB. I WAS TOLD THE HORIZONTAL SIT INDICATOR WAS ROBBED FOR ACFT XYA. MY LEAD TECH TOLD ME THE PART WAS ORDERED EARLIER DURING A DIFFERENT SHIFT AND WAS PULLED FROM STOCK, AND READY FOR, PICK UP AT LINE STORES. I RETRIEVED THE PART FROM STORES AND PROCEEDED TO THE ACFT AND REPLACED THE FIRST OFFICERS HORIZONTAL SIT INDICATOR 'HSI', PER THE AVIONICS JOB CARD. THIS INCLUDED THE USE OF A 'TEST BOX.' OK FOR SVC. I THEN TROUBLE SHOT THE AUTO PLT DISCREPANCY AND FOUND I NEEDED A MODE CTL PANEL. I ASSIGNED A TECH TO ASSIST IN THE REMOVAL AND REPLACEMENT OF THE MCP. THE ACFT WAS MOVED FROM THE HOLDING AREA TO GATE X BY MAINT. AFTER INSTALLING THE MODE CTL PANEL. I WAS NOTIFIED DAYS LATER THAT THE 'HSI' COMPONENT THAT I REPLACED ON ACFT XYZ (FO'S) WAS THE WRONG PART NUMBER. THE WRONG PART NUMBER WAS ORDERED DURING SHIFT FOR ACFT XYZ. A REQUEST FROM ENGINEERING AND RECORDS TO REMOVE THE 'HSI' AND REPLACE WITH ANOTHER PART. THIS WAS ACCOMPLISHED 11/WED/2001 IN ZZZ1, US. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE EFIS INDICATOR HAD BEEN ORDERED ON THE PREVIOUS SHIFT AND WAS INSTALLED WITH A JOB CARD. THE RPTR SAID THE JOB CARD HAS THE SAME INFO AS THE MAINT MANUAL FOR INSTALLATION AND TESTING OF THE INSTRUMENT. THE RPTR STATED THE INSTRUMENT TESTED OK AFTER INSTALLATION AND THE PART NUMBER WAS ENTERED IN THE MAINT COMPUTER AND WAS ACCEPTED. THE RPTR SAID NEITHER THE JOB CARD NOR THE MAINT MANUAL HAD ANY INFO ON EFFECTIVITY OF THE PART FOR DIFFERENT MODELS OF THE B737. THE RPTR STATED THE CARRIER HAS HAD 24 INCIDENTS OF THE WRONG PART INSTALLED AND DOES NOT APPEAR TO BE MAKING IMPROVEMENTS. THE RPTR SAID NO STANDARD EXISTS TO HAVE THE PART NUMBER PAINTED ON THE PART AS SOME HAVE NUMBERS AND OTHERS NONE. THE RPTR STATED THE MAINT COMPUTER HAS MAJOR FLAWS AS IT IS SUPPOSED TO BE PROGRAMMED TO REJECT A PART THAT IS NOT ON THE ACFT EFFECTIVITY LIST, BUT MOST TIMES DOES NOT PERFORM THIS FUNCTION.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.